tbuckley/cabot-search huggingface dataset:
BT06 Using artificial intelligence to triage skin cancer referrals: outcomes from a pilot study
Authors: Karmel Abu Baker, Elizabeth Roberts, Karen Harman, Dan Mullarkey, Dilraj Kalsi
Journal: British Journal of Dermatology (2023)

Abstract Artificial intelligence (AI) is a rapidly emerging field in dermatology, aimed at delivering efficient and effective patient care. To date, there is a lack of substantial evidence for the use of this technology in a clinical setting. However, the pandemic era has placed significant pressures on dermatology services, specifically the skin cancer clinics at our trust, which has experienced a 30% increase in demand compared with prepandemic levels. A novel solution for urgent referrals was to test the use of AI teledermatology software using a UK Conformity Assessed marked Class IIa Medical Device (and therefore regulated by the Medicines and Healthcare products Regulatory Agency). Appropriate cases are selected and booked for a teledermatology appointment at one of our four community-based hubs. Clinical and dermoscopic images, together with a short questionnaire, are uploaded to the software by a healthcare assistant. The AI immediately assesses the dermoscopic images of the lesion, and those cases identified as benign are discharged back to the general practitioner (GP), following a safety check by a consultant dermatologist employed by the AI provider. The trust dermatology consultants have chosen to further triage all cases suspected to be nonbenign. Patients with suitable small lesions at low-risk sites receive a telephone appointment to discuss surgery and obtain consent. Those with precancerous lesions can be discharged back to the GP with management advice. Low-risk basal cell carcinomas case are transferred to a routine pathway. Selected cases may be referred directly to other teams. The pilot started in March 2022 and now processes 5–600 cases per month at four photography hubs. To date, 19% of cases have been discharged back to the GP with a benign diagnosis. A further 15% of cases have been discharged back to the GP by the trust dermatologists, giving an overall discharge rate of 34%. Ten per cent of patients have received a telephone call to take consent for biopsy, and 2% have been referred directly to another speciality. Thirteen per cent of cases have been triaged to a routine pathway, and 38% of patients have required an urgent face-to-face appointment with a dermatologist. The trust has seen &amp;gt; 90% 2-week wait referrals within 2 weeks in the last two quarters. Since the introduction of this AI teledermatology service, we have seen a 62% reduction in the number of patients requiring an urgent face-to-face appointment with a dermatologist. Ongoing audit work is focused on the safety, acceptability and cost-effectiveness of this pathway, and will shape decision-making in the ongoing use of this technology both locally and across the UK.
BT22 The concordance between dermatology doctors in their approach to teledermatology referrals
Authors: Mina Almasi-Nasrabadi, John English, Radha S Ayyalaraju
Journal: British Journal of Dermatology (2023)

Abstract Telemedicine is an innovative, rapidly evolving method of care delivery in the National Health Service. The main long-term benefit of teledermatology triage is to ensure that patients receive timely care in the most appropriate setting, and to increase capacity in secondary care for patients who need face-to-face referrals. However, the diagnosis made and the advice given may vary depending on the experience and knowledge of the person triaging. The aim of this study was to evaluate how the interpretation of the information/images by different clinicians can affect the outcome of a teledermatology referral. The data collected in this project are expected to provide knowledge about the concordance between dermatology doctors in their approach to teledermatology referrals and to evaluate the impact on quality of care. The teledermatology service referrals to our dermatology department are made through the national electronic Referral Service, with the option to attach images or to refer patients to an image-taking clinic based at the hospital. Dermatology consultants will then review referrals virtually, relaying advice back to the referrer. We provided a mixture of 10 teledermatology referrals who had attended the image-taking clinic to dermatology consultants and dermatology trainees. The dermatology doctors were asked to complete an outcome template for each referral based on the information/images provided. The study was completed by nine consultants and four trainees. Only three consultants (33%) and no trainees had previous experience of the teledermatology service. The respondents evaluated the clinical information provided in the referrals as good (41%), satisfactory (47%) and poor (12%). The clinicians evaluated the quality of images taken following the referral as good (68%), satisfactory (28%) and poor (4%). Overall, 90% of the consultants and 72% of the trainees agreed with the final diagnosis/outcome of the teledermatology referral. The benign skin lesions had the least consistency between the clinicians in terms of the diagnosis and type of the follow-up arranged. The follow-ups arranged after a referral included routine referral to clinic (consultants 30%, trainees 32%), urgent referral to clinic (consultants 25%, trainees 40%), referral to clinic if not improved (consultants 21%, trainees 17%) and discharge (consultants 23%, trainees 10%). In conclusion, there was satisfactory concordance between clinicians in responding to the majority of the teledermatology referrals. Trainees have shown to agree with the final diagnosis in the majority of cases; however, they still need more training in this area, particularly on how to gain confidence in arranging an appropriate follow-up plan after the advice given.
PD11 Photodynamic therapy for treating acne vulgaris
Authors: James Ralph, Angela Alani, Trevor Markham, Annette Murphy
Journal: British Journal of Dermatology (2023)

Abstract In recent years, photodynamic therapy (PDT) has been advised as a possible adjunct to conventional therapy for acne vulgaris (acne). Both the 2021 National Institute for Health and Care Excellence acne guidelines and the 2018 British Association of Dermatologists’ PDT guidelines include PDT as an option to consider for acne in those aged 18 and older and if other treatments are ineffective, not tolerated or contraindicated. There is, at present, insufficient evidence to suggest an exact dosage or treatment protocol. Herein, we present a case of successful use of PDT in a patient with difficult-to-manage acne and the protocol employed. A 21-year-old woman has been attending dermatology for 10 years for acne, with keloid scarring, which is most extensive on her back. She was previously treated with spironolactone and a combined oral contraceptive pill. Topical retinoids and antibiotics, including trimethoprim (to which she developed erythema multiforme), clindamycin, azithromycin and tetracyclines, had all been used for various periods without sustained successful clearance. The patient has a general anxiety disorder with low mood and is taking quetiapine. She is a social media advocate for people with mental health issues and has good insight into her mood. She is educated regarding isotretinoin and contraindications to its use. The patient was treated with a trial of two sessions of PDT 1 week apart. The target area was prepared 3 h in advance of light with methyl aminolaevulinate 16% (as hydrochloride) spread to a thickness of 1–5 mm beyond the area border. Red light (635 nm) with a total dose of 37 J cm−2 was provided for 7 min and 50 s each time. The patient has Fitzpatrick skin type I and experienced moderate postprocedural erythema, which later resolved. At both the 3- and 6-month clinical follow-up, the patient is effectively clear of active acne in the treated area. There is previous residual scarring. The patient is not using any topical or systemic acne treatments. Options for acne treatment are diverse. However, some patients experience ineffective clearance or tolerance, and are not good candidates for isotretinoin. Dermatology centres with PDT may help provide an alternative solution. This case illustrates the successful application of PDT for acne and adds to the body of literature to support its inclusion in the aforementioned guidelines.
P58 Sustained improvement in malignant melanoma prognosis at a consultant-delivered multidisciplinary pigmented lesion clinic: a follow-up study
Authors: Róisín McDonnell, Lisa Kiely, Aline Brennan, Joe McDevitt, Deirdre Murray, Michelle Murphy, Mary Bennett, John Bourke
Journal: British Journal of Dermatology (2023)

Abstract Rapid-access clinics are designed to improve the early detection and prognosis of melanoma, but there is little hard evidence in the literature of their effectiveness. We established a pigmented lesion clinic (PLC) in 2002 and have previously demonstrated a subsequent reduction in melanoma thickness at our hospital. We undertook a retrospective cohort study to assess the long-term effects. Data for all melanomas diagnosed in the Republic of Ireland between 1 January 1998 and 31 December 2019 were provided by the National Cancer Registry Ireland (n = 15 619). We excluded T0 and Tis and unknown T melanomas. Our PLC was found to have a higher proportion of tumours diagnosed at an earlier stage of T1 (51.6%) vs. the region/county where the PLC is based (37.8%) and Ireland (40.3%). Following the introduction of the PLC, from 2003 to 2007, a significant difference was noted between our PLC and the rest of Ireland, with a higher proportion of T1 tumours diagnosed (41.6% vs. 29.7%; P &amp;lt; 0.001). For the region, the percentage of T1 tumours was lower than for the rest of the country, but this difference fell short of significance (34.5%; P = 0.057). In the two 5-year periods following this (2008–2013 and 2014–2019), our PLC had significantly more early tumours (44.4% and 62.1%, respectively) than the rest of Ireland (35.9% and 52.2%, respectively; P &amp;lt; 0.001 for both time periods). More PLCs have been established across the country, probably accounting for the higher proportion of early-stage melanomas diagnosed in 2014–2019. The figures for the region were also significantly better than those for the rest of the country [40.7% and 55.7% (P = 0.008 and P = 0.039), respectively], suggesting that the PLC has had an effect on prognosis, resulting in a greater proportion of early melanomas in the region vs. Ireland. Preliminary analysis found a hazard ratio (HR) of 0.78, or a 22% reduced risk death, at 5 years (unadjusted Cox proportional hazard regression on all nonmetastatic melanoma with known T diagnosed 1998–2019, n = 16,489) for those attending the PLC vs. the rest of Ireland. Patients in the rest of the region were found to have a higher HR (1.15) vs. the rest of Ireland. The PLC appears to have contributed to improved prognosis in the region in the years following its establishment. This study supports the long-term benefits of a PLC over the course of more than 20 years.
P25 Considering the burden of scabies alongside a mass drug administration treatment programme in an indigenous community in northern Australia
Authors: Victoria Cox, Michelle Dowden, Crystal Williams, Daniel Engelman, Jennifer Yan, Anna Ralph, Bart Currie, Joshua Francis
Journal: British Journal of Dermatology (2023)

Abstract Scabies is estimated to affect 455 million people worldwide and is one of 20 neglected tropical diseases recognized by the World Health Organization (WHO). It is caused by a parasitic mite infestation that is hyperendemic in low-resource regions, and the disease burden in northern Australia is believed to be among the highest in the world. However, few recent prevalence assessments have been conducted in northern Australia and it is not known whether historical assessments are still representative of the disease burden. Therefore, it is difficult to advocate for the allocation of government funding and resources without accurate information on the burden of disease. Considering the effectiveness of an ivermectin-based mass drug administration (MDA) treatment programme in northern Australia is important to explore a control strategy, following successful large trials conducted in the Pacific and recommendations from the WHO. The aim was to consider the burden of scabies and other skin conditions in an indigenous community in northern Australia, from undertaking a simplified skin assessment of all consenting community residents. An observational cross-sectional study design was used for this purpose. Five field teams covered different regions in Maningrida. The teams were comprised of a medical practitioner from the investigative team who worked alongside a local healthcare worker and an Aboriginal healthcare worker. All community residents who gave verbal consent were administered ivermectin, or topical permethrin cream if ivermectin was contraindicated, as part of a MDA programme, which was locally developed and implemented by the Mala’la Health Service. Simplified skin examinations (n = 1306) were conducted in Maningrida during Healthy Skin Week from 14 to 18 November 2022, with verbal consent from 99% of community residents approached for recruitment to undergo a simplified skin assessment and administration of ivermectin as part of the MDA treatment programme. The point prevalence for scabies was 25.2% (330 individuals). Ninety-three people (7.1%) were diagnosed with impetigo, and approximately 40% of community residents had evidence of skin disease. No study participants were diagnosed with crusted scabies. Scabies is endemic in indigenous communities in northern Australia. This was the first prevalence assessment to be conducted in the Northern Territory since the East Arnhem Healthy Skin Project, which concluded in 2007, and the first MDA treatment programme conducted by an aboriginal medical service as a local health intervention. The consideration of effective rapid mapping and regional control strategies is essential to tailor a public health response that addresses the high burden of skin disease in northern Australia.
BG13 A rare case of Muir–Torre syndrome
Authors: Samuel Ashcroft, Paola De Mozzi
Journal: British Journal of Dermatology (2023)

Abstract Muir–Torre syndrome is a rare variant of hereditary nonpolyposis colorectal cancer, also known as Lynch syndrome. It is caused by a defect in mismatch repair genes, which are most commonly inherited in an autosomal dominant fashion. It is characterized clinically by sebaceous neoplasms of the skin associated with at least one visceral malignancy, with colon cancer being the most frequent. The most common genetic defects responsible are in MLH1, MSH2 and MSH6, which results in an increased frequency of unrepaired base mismatching during DNA replication and subsequent microsatellite instability, predisposing to cancer. We present a case of a 59-year-old man with a history of colon cancer who was referred with a rapidly growing irregular nodule on his lower back for the past 2 months, concerning for an amelanocytic melanoma. An excision biopsy was arranged, and subsequent histology demonstrated a sebaceoma. Immunohistochemistry for mismatch repair genes showed loss of expression for MSH2 and MSH6. Upon further questioning, it was found that he had a strong family history of colon cancer (father, brother and two sisters), and he developed colon cancer at 36 years of age, which was treated with a pancolectomy. Genetic testing revealed a mutation in MSH2. Given this history, annual follow-up was arranged for skin surveillance.
DP08 Next-generation sequencing: the future for malignant melanoma diagnostic precision? A case of a <i>BAP1</i> mutation
Authors: Amy Cunliffe, Rand Hawari, Maulina Sharma
Journal: British Journal of Dermatology (2023)

Abstract A 48-year-old man presented to the hand surgeons with a 5-year history of a subcutaneous swelling on his right wrist, associated with paraesthesia and pain, initially thought to be a benign ganglion. Excision biopsy of the lesion on histology revealed an encapsulated pleomorphic tumour attached to a nerve, thought to represent a sarcoma. Immunohistochemistry showed a positive reaction to S100, SOX10, calretinin and synaptophysin. Ki67 showed a 20% proliferation index. Multiple pathology opinions were sought, and further testing was performed at a specialist genomic laboratory. Detailed questioning regarding family history of malignancy revealed that the patient’s mother had died from metastatic uveal melanoma, a maternal aunt had died of a brain tumour and his maternal grandmother had lung cancer. Pan-cancer gene panel DNA next-generation sequencing showed a BAP1 mutation with a very high variant allele fraction, suggestive of germline inheritance. Given the clinical history, morphology, immunoprofile and DNA result, a favoured diagnosis of metastatic malignant melanoma with a BAP1 mutation was made. The patient was referred to the specialist skin cancer multidisciplinary team meeting and reviewed by the dermatology team. Full skin check examination revealed two long-standing atypical naevi (&amp;gt; 10 years), one on the left forearm and another on his back, and these were excised urgently. Histology of the back lesion showed a polypoid melanocytic tumour comprising large epithelioid melanocytes with mild-to-moderate nuclear pleomorphism, multinucleated cells and intranuclear inclusions. This was in keeping with a pT4a nodular malignant melanoma with 7-mm Breslow thickness, associated with BAP1-inactivated syndrome. Histology of the left forearm lesion was consistent with a combined BAP1-inactivated melanocytoma, otherwise known as a ‘BAPoma’. An ophthalmology review did not identify a primary uveal melanoma. Staging scans of his chest, abdomen and pelvis and magnetic resonance imaging of his head showed no evidence of metastatic disease. The patient was referred for genetics counselling, wide local excision of the melanoma on his back, for consideration of adjuvant therapy with oncology and long-term follow-up with dermatology. BAP1 tumour predisposition syndrome is a newly recognized cancer syndrome that predisposes the patient to uveal melanoma, malignant mesothelioma, renal cell carcinoma, cutaneous melanomas and a range of other cancers (Masoomian B, Shields JA, Shields CL. Overview of BAP1 cancer predisposition syndrome and the relationship to uveal melanoma. J Curr Ophthalmol 2018; 30:102–9). BAP1-related cancers tend to occur earlier in life and are more aggressive. Our case highlights the need for early identification of germline mutations through sequencing to improve outcomes and treatment-related morbidity by early diagnosis in these rare cancer syndromes.
P40 Dupilumab treatment restores skin barrier function in lesional and nonlesional skin of patients with atopic dermatitis and improves patient-reported outcomes
Authors: Michael Cork, Robert Bissonnette, Marco Ramirez-Gama, Patricia Taylor, Amy Praestgaard, Noah Levit, Ana Rossi, Annie Zhang
Journal: British Journal of Dermatology (2023)

Abstract The objective of this analysis is to report the effect of dupilumab treatment on skin barrier function and patient-reported outcomes (PROs) in adults and adolescents with moderate-to-severe atopic dermatitis (AD). BALISTAD (NCT04447417) was an open-label trial in which transepidermal water loss (TEWL) was assessed repeatedly before and after skin tape stripping (STS) samples were taken from lesional and nonlesional skin of 26 patients with AD treated with dupilumab, and from normal skin of 26 matched healthy volunteers aged 12–65 years over a period of 16 weeks. PROs assessed included Patient-Oriented Eczema Measure (POEM), Peak Pruritus Numerical Rating Scale (PP-NRS) and Dermatological Life Quality Index [DLQI; for patients &amp;gt; 17 years old; Children’s DLQI (CDLQI) for patients aged &amp;gt; 12 to &amp;lt; 17 years]. At baseline, the median TEWL after five STS was statistically significantly higher in the lesional and nonlesional skin of patients with AD compared with healthy skin (P &amp;lt; 0.001 and P &amp;lt; 0.01, respectively) and statistically significantly decreased following dupilumab initiation as early as week 2 (P &amp;lt; 0.001 and P &amp;lt; 0.05, respectively). After 16 weeks of dupilumab treatment, there was no statistically significant difference in adjusted mean TEWL in AD lesional and nonlesional skin compared with matched healthy skin (P = 0.225 and P = 0.163, respectively). Significant improvement from baseline [mean (SD) change from baseline] was seen as early as week 2 in mean POEM [−8.4 (5.1)], DLQI [−5.3 (4.7)], CDLQI [−6.2 (4.7)] and PP-NRS [−2.2 (1.8); P &amp;lt; 0.001 and P &amp;lt; 0.05)] for CDLQI. Improvement was sustained through to week 16 [mean (SD) change from baseline; P &amp;lt; 0.001] for POEM [−13.6 (8.5)], DLQI [−8.6 (7.4)] and PP-NRS [−4.2 (2.6)] and with a P-value of &amp;lt; 0.01 for CDLQI [−9.2 (5.0)]. Dupilumab treatment normalizes epidermal barrier function in lesional and nonlesional skin in patients with moderate-to-severe AD, as measured with TEWL, and improves PROs. Funding sources: research sponsored by Sanofi and Regeneron Pharmaceuticals Inc.